The culture of clinicians treating pain as a fifth vital sign, targeting pain-free living through a prescription regimen, is acknowledged as a driving factor behind the rise of opioid addiction.
The American Society of Addiction Medicine found 4 in 5 new heroin users began by abusing prescription painkillers.
Geisinger Health System took efforts to change that culture internally, slashing by half its opioid prescriptions and focusing instead on a regimen of pain management combining physical therapy with changes in diet and behavior.
Opioid prescriptions dropped from a monthly average of 60,000 to 31,000 since 2014, according to the health system. How Geisinger got there came, in part, through examining data already being collected and shifting to electronic prescribing.
The health system's analytics and information technology teams developed an electronic provider dashboard to identify and track the highest-prescribing clinicians. Geisinger combined that data with the latest research in best prescribing practices, first educating heavy prescribers before eventually addressing the matter with clinicians system-wide.
Clinicians were urged to explore treatment alternatives to medication and directed to use the state's Prescription Drug Monitoring Program that prevent doctor-shopping that fuels an illegal market for pain pills.
Mike Evans, Geisinger's chief pharmacy officer, said clinicians deal in singulars. They're examining the patient, not population data.
"As we put it in front of them, the typical response we received was, 'wow, I didn't know I was prescribing that much,'" Evans said.
Geisinger's Chief Information Officer John Kravitz estimated the investment to initiate these changes at under $500,000. Aside from helping change prescribing practice, it's created new efficiencies in time and resources that save an estimated $1 million annually, he said.
"There is no surgery that's pain-free," said Kravitz, who testified before a Congressional committee in April about Geisinger's electronic efforts. "In the past, we may have prescribed 10 days or 30 days of opioids depending on the type of surgery. Now, what's been explained to me by our pharmacy folks and our providers is that we will alternate between Tylenol or Motrin or Ibuprofen, back and forth. A patient should expect a degree of pain with surgery."
Patients who do get prescriptions, with exceptions like in oncology, get a seven-day maximum supply.
Electronic prescribing began in August for controlled substances, with three of four narcotic now prescribed electronically. It takes two steps to authorize a prescription, and the order is shipped direct to a pharmacy, eliminating the opportunity to alter the dosage or pill count. This summer, Evans said Geisinger will end paper prescribing altogether.
Evans observed the system in action as it was developed and said watching patients in real-time attempt to cheat the system was striking.
"We had patients that were those abusers, they left the system because they knew we were watching. In reality, we wanted to get them help," Evans said.
As Geisinger continues toward full electronic prescribing, Evans acknowledged the importance of cyber security and how hacking is a threat for illegal drug diversion just as is altering a paper prescription.